The Benefits of Triage and the COME HOME Model

Orlando, FL—At the heart of the oncology medical home is triage, according to Barbara McAneny, MD, Chief Executive Officer of New Mexico Cancer Center as well as Innovative Oncology Business Solutions (IOBS), where she also serves as chief medical officer.

IOBS was awarded a $19.76-million grant from the Center for Medicare & Medicaid Innovation to develop a Community Oncology Medical Home (COME HOME) model and implement that model in 7 community oncology practices around the country.

"The COME HOME vision is all centered around triage," said Dr McAneny at the 2016 Community Oncology Conference.1 "We try to make sure that when patients call in they reach someone who knows something about their disease, the drugs they're taking, and the side effects, and also about them as a person, so that they can get the care they need."

The COME HOME Model

According to 2008 data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool, presented by researchers in the Journal of Clinical Oncology, 63.2% of the 37,760 emergency department (ED) visits by cancer patients in that year resulted in admissions, mostly for control of such symptoms as pain, respiratory problems, and gastrointestinal issues.2 Medical homes, on the other hand, have been shown to reduce inpatient admissions by 15% to 50%, and in just the first year of the COME HOME program, practices saw a 9.5% reduction in inpatient admissions (from 38.28% to 34.63%), she reported.

"What patients value the most is being at home with the people they love, not spending time in the hospital or cancer center," Dr McAneny stated. Moreover, hospital admissions are known to create additional financial hardships for patients. "I can't help the cost of the drugs, but I can keep them out of the hospital," she added.

COME HOME clinics deliver all outpatient cancer care, and their triage system ensures that patients receive the right care, in the right place, at the right time, by helping them manage the side effects of their cancer and its treatment at the most cost-effective site and at the earliest stage of development.

"We found that if you go to the ER and you're a cancer patient and you're skinny and bald, your chances of being admitted are about 2 out of 3 whether you need to be admitted or not," she said. "So if we can avoid that, we'd like to. We found that we could do a fair amount of savings for patients, practices, and the entire healthcare system, which is a good thing."

IOBS created the COME HOME triage system to provide aggressive, standardized symptom management for patients, thereby reducing ED utilization and inpatient admissions and costs.

"Patients don't call up and say, 'I have squamous cell carcinoma of the tonsil,' they call and say 'my throat hurts,'" said Dr McAneny. So when a patient calls in, a first responder focuses on 1 of 38 symptom-specific pathways (eg, pain, nausea and vomiting, fatigue), utilizing a real-time, web-based decision support system that is already populated with patient demographic data. Then, if the caller is not experiencing a true medical emergency necessitating immediate admission to a hospital, the first responder places the patient-related calls on a dashboard for the triage nurses. The triage nurses then take the calls from the dashboard and begin the triage assessment.

Standard order sets are already outlined in the system for defined patient groups (eg, patients on chemotherapy with fever are scheduled for same-day appointments and have chemistry and complete blood counts ordered without needing physician sign-off for every patient). "We have schedules that have blanks, and the nurses have the power to fill them," she added. "They don't have to ask permission or forgiveness."

The triage pathways guide the triage nurses by providing better patient management, improving timeliness and coordination of care, ensuring safe and seamless care, and enhancing patient care experiences, she said. A second dashboard is used to follow up on patients and is used only by the triage nurses.

According to Dr McAneny, in a community oncology practice, $10,000 a month supports 1 triage nurse plus all associated infrastructure and triage support for 250 patients on active chemotherapy or 2000 total active patients. But in a hospital, the same amount of money supports only approximately 8 ED visits or 1 hospitalization.

After implementation of the COME HOME model, New Mexico Cancer Center experienced a 35.9% drop in the percentage of patients with ED visits, a 43.1% drop in the percentage of patients with inpatient admissions, a 23.8% drop in inpatient days, and a $4784 (22.4%) drop in 6-month total cost of care, she reported. With utilization of the COME HOME model, they estimate a savings of approximately $175,000 per practice, per month.

"We have to get the patients what they need, when they need it, and we have to have a system behind it to make sure we can do this properly," Dr McAneny added. "And when we do that, we can have fewer days in the hospital, which is of value to my patients primarily, and is of huge value as well to whoever is paying the bills."